~ Ride Date: 9-11-2004
>> Registration Form in PDF format ~ Download Adobe PDF Instructions
Print & Mail Registration Form
TO REGISTER: Please print this form, complete all information, then Mail in a completed copy of this registration and waiver form along with your check.
One Form Per Applicant! Photocopy this form for any additional riders.
Sex: M___ F___ Age:______
City:__________________________________________ State:_________ Zip:____________________
Phone: ( )___________________________
Emergency Contact:________________________________________ Phone: ( )________________
We MUST have an emergency contact name and phone number (of someone not attending the ride)!
|Registration - Ride Fees:||Quantity||Price||Amount|
|34 Miles - Metric 1/2 Century:||
|64 Miles - Metric Century:||One||$25.00 =||$_________|
|100 Miles - The Century:||One||$30.00 =||$_________|
|Late Fee: (after 8/30/04)||One||$5.00 =||$_________|
|Extra Meal Ticket(s):||________ x||$8.00 =||$_________|
|Tour T-shirts:||S_____||M_____||L_____||XL______||XXL______ x||$12.00 =||$_________|
(after 8-30-04) :
|S_____||M_____||L_____||XL______||XXL______ x||$15.00 =||$_________|
|RV Space at Fair Grounds||Friday night only||$12.00 =||$_________|
|Camping||Friday night only||$9.00 =||$_________|
NOTE: T-Shirts are not included in the Ride Fee. All rides include a lunch served from 11:30 am to 5:30 pm. Helmets are mandatory for ALL riders. Make checks payable to "The Siskiyou Century" and mail this form to: The Siskiyou Century c/o Yreka Chamber of Commerce, 117 West Miner St., Yreka, CA 96097. If you have any questions E-mail: firstname.lastname@example.org or call us at 530-842-1649.
Accident Waiver And Release Of
In consideration of my acceptance for entry in the SISKIYOU CENTURY for 2004 I hereby waive, release and discharge any and all claims for damages for death, personal injury, or property damage which I may have or which hereafter may accrue to me, as a result of my participation in said event. This release is intended to discharge in advance the promoters, sponsors, and any involved municipalities or other public entities and their respective agents and employees, from and against any and all liabilities arising out of or connected in any way with my participation in said event, even though that liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above.
I further understand that this event will require me to engage in strenuous physical activity at high altitude and in possible adverse weather conditions. I further understand that serious accidents occasionally occur during bicycle riding; and the participants in bicycle riding occasionally sustain mortal or serious physical injury, and/or property damage, as a consequence thereof. Knowing the risk of bicycle riding, nevertheless, I hereby agree to assume these risks and to release and hold harmless all persons or entities mentioned above who (through negligence or carelessness), might otherwise be liable to me (or my heirs or assigns) for damages. It is further understood and agreed that this waiver, release and assumption of risk, is to be binding on my heirs and assigns.
I further agree to abide by all the rules and regulations set forth in this event. I acknowledge that an approved helmet is required to be worn by me at all times while riding during these events. Section 1542 of the civil code of the state of California which provides: "a general release does not extend to claims which the creditors does not know or suspect to exist in his fervor at the time of executing the release, which if know to him must have materially affected his settlement with the debtor:, and all laws of all other states of like, or similar affect, and the benefits thereof, are hereby waived.
All riders being registered must sign this release!
|NAME___________________||AGE_______||SIGNATURE________________________ DATE: ____________|
S ignature of parent or guardian is required if applicant is under 18 years --
No one under 13 may ride unless accompanied by an adult!
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